However, little is known about the demographic characteristics, comorbidities, prior medication uses, and health care cost implications of patients initiated on treatment with duloxetine
Trang 1R E S E A R C H A R T I C L E Open Access
Treatment patterns associated with Duloxetine and Venlafaxine use for Major Depressive
Disorder
Wenyu Ye1, Yang Zhao1, Rebecca L Robinson1, Ralph W Swindle2*
Abstract
Background: Duloxetine and venlafaxine extended release (venlafaxine XR) are SNRIs indicated for the treatment
of MDD This study addresses whether duloxetine and venlafaxine XR are interchangeable in their patterns of use with patients who are depressed or are used more selectively based on treatment history, background
characteristics, and presenting symptoms
Methods: This was a retrospective analysis of an administrative insurance claims database We studied patients in managed care with major depressive disorder (MDD) treated with duloxetine or venlafaxine XR Predictors of treatment and cost were assessed using Chi-square and logistic regression analyses of demographics and past-year medication use and comorbidities
Results: Patients with MDD treated with duloxetine (n = 9,641) versus venlafaxine XR (n = 8,514) tended to be older, slightly more likely to be female, and treated by a psychiatrist (P < 0.0001) In the prior year, more duloxetine patients (vs venlafaxine XR) received≥3 unique antidepressants (20.8% vs 16.6%), ≥3 unique pain medications (25.5% vs 15.6%), and had≥8 unique diagnosed comorbid medical and psychiatric conditions (38.6% vs 29.1%) The prior 6-month total health care costs were $1,731 higher for duloxetine than for venlafaxine XR and declined for both medications in the 6 months after treatment began Logistic regression analysis revealed that 61% of duloxetine patients and 61% of venlafaxine XR patients were predictable from prior patient and treatment factors Conclusions: Patients with MDD treated with duloxetine tended to have a more complex and costly antecedent clinical presentation compared with venlafaxine XR patients, suggesting that physicians do not use the medications interchangeably
Background
Selective serotonin-reuptake inhibitors (SSRIs) and
sero-tonin norepinephrine-reuptake inhibitors (SNRIs) are
mainstays in the pharmacologic management of major
depressive disorder (MDD) in the United States [1]
SSRIs, such as sertraline, paroxetine, fluoxetine, and
escitalopram/citalopram, have been used for years
How-ever, recent studies demonstrated that fewer than 30%
of patients with MDD experience remission with initial
SSRI treatment, and approximately 33% of nonremitting
patients fail to accept an alternative second treatment
[2] Some clinical studies and meta-analyses suggest that
SNRIs may be more effective than SSRIs in ameliorating depressive symptoms in some circumstances [3-5], in achieving greater remission rates [6,7], and in second-line use after poor initial treatment response [8,9] Data based on analyses of clinical trials are inconsistent, how-ever [10-14] This study examines the differential real-world use and cost impact of the SNRIs duloxetine hydrochloride and venlafaxine hydrochloride extended release (venlafaxine XR) in the treatment of MDD Both duloxetine and venlafaxine XR are SNRIs indi-cated for the treatment of MDD Duloxetine and venla-faxine XR have similar mechanisms of action, but duloxetine has a more balanced affinity for both seroto-nin and norepinephrine transporters, whereas venlafaxine has a higher affinity for serotonin than norepinephrine transporters [15,16] Clinically, duloxetine has additional
* Correspondence: swindle@lilly.com
2 Global Health Outcomes, Eli Lilly and Company, Indianapolis, Indiana, USA
Full list of author information is available at the end of the article
© 2011 Ye et al; licensee BioMed Central Ltd This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
Trang 2pain-related indications for peripheral diabetic
neuro-pathic pain and fibromyalgia [17] These different
phar-macologic and indication profiles may lead practicing
physicians to target different types of patients with MDD
for different SNRIs
Many factors may be associated with psychiatrists’
selection of an antidepressant In previous studies,
con-siderations involved in the psychiatrist’s selection of an
antidepressant included the presence of specific
symp-toms (52.3%), the presence of a comorbid psychiatric
disorder (45.6%), previous treatment response (either
positive [17.0%] or negative [25.9%]) [18], previous
anti-depressant use [19], and sex- and age-related differences
[20] However, little is known about the demographic
characteristics, comorbidities, prior medication uses, and
health care cost implications of patients initiated on
treatment with duloxetine compared with venlafaxine
XR No known studies have compared factors that
might predict treatment initiation with one SNRI or the
other and the potential impact of differential selection
Consequently, we sought to examine associations of
demographics, prior comorbidities, medication use, and
treatment cost, with treatment initiation for the two
SNRIs among patients with MDD, using a large US
administrative claims database This study addresses
whether these two medications are essentially
inter-changeable in their actual patterns of use for patients
who are depressed or are used more selectively for
patients with different kinds of treatment histories,
background characteristics, and presenting symptoms
Methods
Data Source and Patient Selection
A retrospective study was conducted using data extracted
from a large nationwide US administrative claims
data-base (PharMetrics Integrated Outcomes Datadata-base) dating
from July 2004 through July 2006 PharMetrics data
represent more than 70 different managed-care
organiza-tions across the United States and more than 58 million
commercially insured patients The PharMetrics database
is Health Insurance Portability and Accountability Act
(HIPAA) compliant, de-identified, commercially available
to the public, and widely considered exempt from
institu-tional review board (IRB)/ethics committee approval
Due to full data de-identification on the collected data,
IRB approvals were neither needed nor sought The data
encompasses comprehensive records on member
demo-graphic characteristics, health plan enrollment, inpatient
and outpatient services, and prescriptions
Diagnostic and prescription data were extracted for
12 months before the date of treatment initiation
with duloxetine or venlafaxine XR (index date), between
July 1, 2005, and July 30, 2006 The index date was
defined as the date of the most recent prescription for duloxetine or venlafaxine XR where no prescription for
or use of the same medication was present in the prior
3 months Patients were included in the study if they were commercially insured, 18 to 64 years of age on the index date, and had 1 or more diagnosis of MDD ( Inter-national Classification of Diseases, 9th Edition [ICD-9-CM] codes 296.2x for MDD single episode, or 296.3x for MDD recurrent episode) during the 12 months before the index date Study patients were also required
to have continuous enrollment for the 12 months before the index date Patients were categorized into two mutually exclusive study cohorts based on the most recent index pharmacy claim: either for duloxetine or venlafaxine XR
Study Variables
For patients in each cohort, we used National Drug Codes (NDC) to identify and categorize prior medica-tions in the 12 months before index SNRI initiation, including antidepressants (SSRIs, monoamine oxidase inhibitors [MAOIs]; tricyclic antidepressants [TCAs]); anxiolytics; other psychotropic medications (e.g., antipsy-chotics, stimulants, atomoxetine, antimanics); sedatives/ hypnotics; anticonvulsants; pain-related medications (analgesics, skeletal-muscle relaxants, antimigraine medi-cations); other medications for gastrointestinal, cardio-vascular, and respiratory diseases; diabetes mellitus; or allergies Two additional variables were created to predict initiation of treatment with duloxetine versus venlafaxine
XR based on prior uses of antidepressants and pain medi-cations: prior uses for≥3 unique antidepressants and ≥3 unique pain medications
Comorbid diagnostic histories were identified based
on ICD-9-CM codes in the 12 months leading up to and including the index visit Medical conditions consid-ered were other depressive disorders (300.4x for dysthy-mic disorder, 309.1x for adjustment reaction with prolonged depressive reaction, and 311.x for depressive disorder not elsewhere classified), pain, diabetic neuro-pathy, fibromyalgia, anxiety (classified as generalized anxiety disorder, panic anxiety, post-traumatic stress dis-order, social anxiety, and other anxiety disorder), schizo-phrenia, bipolar disorder, organic psychosis, alcohol dependence, dyslipidemia, hypertension, sleep disorders, gastrointestinal disorders, diabetes mellitus, asthma, heart disease, attention-deficit/hyperactivity disorder (ADHD), drug dependence, and nondependent drug abuse Specific pain diagnostic subcategories were also identified, including skeletal muscle, back, head, chest, neuropathic pain, irritable bowel syndrome, and other pain conditions not classified elsewhere (ICD-9 coding groups available from corresponding author on request.)
Trang 3On the basis of prior diagnoses, a predictive indicator
variable for patients with ≥8 unique medical disease
classes was derived (see Appendix)
To compare health care utilization between the two
SNRI cohorts, we calculated total health care costs
based on amounts paid by health plans for medical
ser-vices and prescription medications for 6 months before
(and including the index date) and the 6 months after
the index date Medical costs were classified by place of
service into inpatient, emergency room, outpatient, and
pharmacy costs
Statistical Analyses
The following factors were compared for patients in the
duloxetine cohort with those in the venlafaxine XR
cohort: sociodemographic characteristics (age [mean age
and by-group ages 18-35, 36-50, and 51-64 years],
gender, plan type, geographic region, and prescriber
spe-cialty (psychiatrist or other at the index date), prior
medication use, prior medical conditions, and health
care claims costs for the patients Chi-square and
Man-tel-Haenszel tests were performed for comparisons of
categorical variables between cohorts, and 2-sample t
tests, Wilcoxon signed-rank, and wilcoxon rank-sum
test were performed for comparisons of continuous
variables
To determine predictors of initiation with duloxetine
versus venlafaxine XR, a multivariate logistic regression
model was used, with initiation of treatment with
duloxe-tine versus venlafaxine XR as a binary dependent variable
coded as 1 = duloxetine and 0 = venlafaxine XR
Covari-ates in the model included patient age (with age 18-35
years as a reference group), gender, prescriber specialty,
dummy variables for prior medication use, and medical
and diagnostic histories Additional predictors included 3
derived indicators for prior uses of≥3 unique
antidepres-sants and≥3 unique pain medications and patients with
≥8 unique disease classes Adjusted odds ratios (ORs)
and 95% confidence intervals (CIs) are presented to show
the strengths of the associations with each significant
predictor in the model The reliability of the model was
checked to evaluate predictability values, including
recei-ver-operator characteristic (ROC) curves All statistical
analyses were performed using SAS version 9.1 (SAS
Institute, Inc., Cary, NC) Tests were conducted at a
two-taileda = 0.05 Two-tailed p-values are presented
unad-justed for multiplicity However, as a total of 65 different
covariates were examined, Hochberg’s adjustment was
computed and p-values of approximately 0.001 or less
met the multiplicity adjusted level of statistical
signifi-cance [21] Thus, p-values of 0.001 or less are denoted as
statistically significant in the tables
Results
A total of 18,155 patients with MDD met the selection criteria, including 9,641 (53%) patients initiating treat-ment with duloxetine and 8,514 (47%) patients initiating with venlafaxine XR Patients in the two cohorts differed
in sociodemographic characteristics (Table 1) Patients initiating treatment with duloxetine were older and slightly more likely to be female (P < 0.0001) Duloxe-tine was significantly more likely to be used in the east-ern, southeast-ern, and western regions of the United States and venlafaxine XR in the Midwest In addition, a higher proportion of patients initiating treatment with duloxe-tine (vs venlafaxine XR) received prescriptions from psychiatrists (P < 0.0001)
Prior Medication Use
Higher proportions of patients initiating treatment with duloxetine (vs venlafaxine XR) previously received pre-scriptions for psychotropic medications, including SSRIs, TCAs, other antidepressants, anxiolytics, antic-onvulsants, and antipsychotics(All significant P < 0001; Table 2) In addition, significantly higher proportions of patients initiating treatment with duloxetine previously received medications for painful conditions during the year before the index date This finding was consistent (P < 0.0001 for each comparison) across each class of medications examined, including analgesics (63% vs 51%), skeletal-muscle relaxants (27% vs 17%), and anti-migraine medications (12% vs 9%) Other medication classes were also prescribed to higher proportions of patients initiating treatment with duloxetine compared with venlafaxine XR during the year before the index date, including hypnotics (30% vs 22%) and antiulcer (29% vs 23%) medications (P < 0.0001 for each com-parison) Furthermore, a slightly higher proportion of patients in the duloxetine cohort in the previous year received ≥3 unique antidepressants (21% vs 17%), and 26% of duloxetine patients received ≥3 unique pain medications compared with 16% for venlafaxine XR (P < 0.0001)
Comorbid Conditions
Slightly higher proportions of depressed patients trea-ted with duloxetine compared with venlafaxine XR had prior diagnoses of comorbid medical conditions during the 12 months before the index date (Table 3) Patients initiating treatment with duloxetine were more likely
to have≥8 unique medical conditions compared with those treated with venlafaxine XR (39% vs 29%; P < 0.0001) Individuals beginning treatment with duloxe-tine were also significantly more likely than those tak-ing venlafaxine XR to have prior pain in the diagnostic
Trang 4subcategories evaluated, including muscle (56% vs.
43%), back (34% vs 25%), head (25% vs 21%), chest
(20% vs 17%), or other pain (27% vs 23%) (P < 0.0001
for each comparison vs venlafaxine XR) Those
initiat-ing treatment with duloxetine were also more likely to
have prior fibromyalgia diagnosed than their
counter-parts initiating therapy with venlafaxine XR (17% vs
10%;P < 0.0001)
Predictors of Duloxetine Treatment
Adjusted logistic regression modeling revealed
pretreat-ment factors that uniquely predicted treatpretreat-ment with
duloxetine or venlafaxine XR (Figure 1) Older patients
(>35 years) were more likely to be initially treated with
duloxetine compared with venlafaxine XR (P < 0.05)
Patients were more likely to be treated with duloxetine
if they had previously received prescriptions for SSRIs,
TCAs, other antidepressants, anticonvulsants, atypical
antipsychotics, analgesics, hypnotics, muscle relaxants,
stimulants, or antihistamines, or if they had a diagnosis
of sleep disorder during the previous 12 months (P <
0.05) Further, duloxetine treatment was significantly
associated with previous prescriptions for ≥3 unique
pain medications and with receiving prescriptions from
a psychiatrist compared with other physicians Initial
treatment with venlafaxine XR was more likely in
patients who had received prescriptions for typical
anti-psychotics (P = 0.037) or had a diagnosis of drug abuse
(P = 0.001)
A sensitivity analysis for the logistic analysis was con-ducted to examine for the impact of continuous coding
of the prior antidepressant, prior pain medication, and prior medical cormorbidity categories Utilizing continu-ous versions of the variables did not change the infer-ence (whether they are statistically significant or not) for these factors
Model reliability checking supported the results of the regression analysis Based on the logistic regression ana-lysis using prior demographic characteristics, prescrip-tion by a psychiatrist, and diagnostic and prescripprescrip-tion histories, it was possible to correctly predict 61% of patients who initiated treatment with duloxetine and 61% of patients who initiated treatment with venlafaxine
XR The area under the ROC curve (AUC) was 0.64
Health Care Costs
The distribution of health care costs in the 6 months before and 6 months after the index date is presented in Figure 2 On average, patients in the duloxetine cohort incurred significantly higher prior total health care costs (P < 0.005) The average prior 6-month total cost for patients initially treated with duloxetine was $10,239 and for patients treated with venlafaxine XR, $8,508 Although total pharmacy costs increased by more than
$200 for each medication cohort in the subsequent
6 months (P < 0.001), average medical costs significantly decreased for each cohort (P < 0.001), resulting in a net average significant decrease in total health care cost in
Table 1 Demographic characteristics and health care provider for patients initiating therapy with duloxetine versus venlafaxine XR
(n = 9,641)
Venlafaxine XR Group (n = 8,514)
p-value
XR = extended-release Indemnity - a type of fee-for-service medical plan that reimburses the patient and/or provider as expenses are incurred All comparisons
of demographics between cohorts are statistically significant (at least P < 0.001), except those marked by (NS = Not statistically significant).
Trang 5the 6 months after SNRI initiation of $546 for the
duloxetine cohort and $725 for the venlafaxine XR
cohort (P < 0.05)
Discussion
This study examined existing clinical practice patterns
of SNRIs duloxetine and venlafaxine XR to determine if,
in usual clinical practice, they appear to be used as
interchangeable medications or if there is evidence of
targeted use of each for more specific MDD patient
populations The evidence favors targeted use: logistic
regression prediction of treatment choice from
pretreat-ment characteristics is substantially higher than 50%,
which would be expected for a random choice between
the 2 SNRIs In our logistic regression analysis, 61% of
patients receiving initial prescriptions for duloxetine and 61% for venlafaxine XR were predictable from pretreat-ment characteristics
Patients with MDD who were initially treated with duloxetine tended to be older and to have more com-plex clinical presentations compared with their counter-parts treated with venlafaxine XR During the year before initiating SNRI treatment, future duloxetine patients were more likely than future venlafaxine XR patients to have a history of comorbid psychiatric and nonpsychiatric conditions, including pain More duloxe-tine initiators were also likely to have previously taken other medications for mood, pain, and other medical conditions and were more likely to have received pre-scriptions for≥3 distinct antidepressants in the previous
Table 2 Medication use in the prior 12-month period for patients initiating therapy with duloxetine versus
venlafaxine XR
Previous Medication Use Duloxetine Group, %
(n = 9,641)
Venlafaxine XR Group, % (n = 8,514)
p-value Antidepressants
Other medications
ADHD medications
XR = extended release; SSRIs = selective serotonin reuptake inhibitors; TCAs = tricyclic antidepressants; MAOIs = monoamine oxidase inhibitors; ADHD = attention-deficit/hyperactivity disorder All comparisons of medication use between cohorts are statistically significant at least P < 0.001), except those marked by (NS = Not statistically significant).
Trang 6year As would be expected with a greater comorbid
dis-ease burden, patients commencing therapy with
duloxe-tine were also more likely to have had higher previous
health care resource utilization and total health care
costs compared with the venlafaxine XR cohort Use of
either medication was associated with a net reduction in
total medical costs in the 6 months after their initiation,
despite higher pharmacy costs
These findings of substantial differences in
pretreat-ment case mixes and costs between patients initiating
treatment with either of the two SNRIs in actual
prac-tice patterns appear to be at odds with what might be
expected based on their efficacy with each other and
with the SSRIs, as reported in clinical trials and
com-parative effectiveness meta-analyses [13,14] We suspect
that a reason for this apparent discrepancy of trial data from real-world use is the emerging clinical practice pattern of successive step therapy [22,23], as most pro-minently illustrated in the Sequenced Treatment Alter-natives to Relieve Depression (STAR-D) effectiveness trial [9] The STAR-D studies mimic real-world care by initiating treatment with SSRI in all patients, then offer-ing nonremittoffer-ing patients recommended second-step and third-step treatments In STAR-D [2], nonremitting patients requiring additional treatment steps were pre-dicted by many of the same pretreatment characteristics reported herein: prior treatment nonresponse, multiple comorbid medical conditions, multiple psychiatric comorbidities, as well as more severe depressive symp-toms (data not available in this study) In STAR-D
Table 3 Comorbid medical conditions in the prior 12-month period for patients initiating therapy with duloxetine versus venlafaxine XR
(n = 9,641)
Venlafaxine XR Group, % (n = 8,514)
p-value
GAD = generalized anxiety disorder; PTSD, = post-traumatic stress disorder; ADHD = attention-deficit/hyperactivity disorder All comparisons of comorbidities between cohorts are statistically significant (at least P < 0.001), except those marked by (NS = Not statistically significant).
Trang 7terms, patients taking SNRIs and examined in this study
appear to resemble nonremitting, complex, Step 2 and
Step 3 patients Thus, in contrast to clinical trials, which
randomize average patients to different treatments,
SNRIs are more often initially prescribed to patients
with a more complex and challenging clinical picture in
usual clinical care Use of the SNRIs for complex
patients is in line with emerging studies suggesting that
SNRIs may be particularly effective in patients with a
more severe and complicated initial clinical presentation
who are most prone to fail first-line SSRI treatment [6-8]
To best of the authors’ knowledge, this is the first
study to assess the association of demographics, prior
comorbidities, medication use, and treatment cost, with treatment initiation for duloxetine and venlafaxine XR
in the usual care of patients with MDD The findings demonstrated that duloxetine is primarily used for patients with a complicated disease and medication profile
Potential Study Limitations
As with most other retrospective administrative claims data analyses, this study is subject to potential limita-tions, including selection biases and unmeasured con-founding factors We examined individuals who were commercially insured and had 12 months of continuous
Figure 1 Adjusted odds ratios and 95% confidence intervals for significant predictors of initiating treatment with duloxetine compared with venlafaxine XR XR = extended release; SSRIs = selective serotonin reuptake inhibitors; TCAs = tricyclic antidepressants; MAOIs
= monoamine oxidase inhibitors; ADHD = attention-deficit/hyperactivity disorder.
Trang 8enrollment; patients who did not meet these inclusion
criteria were excluded We also selected the most recent
initiation of SNRIs in patients with MDD diagnoses, and
this method diverges from the usual practice of starting
with an incident diagnosis and having the first
medica-tion define an index case in claims studies Data on
MDD severity, treatment outcomes, patient preferences,
and health plan restrictions were also unavailable;
hence, comorbidities and health care resource utilization
serve as indirect indicators of disease severity and
out-come Although our logistic regression models adjusted
for certain confounding factors, potential biases may
still exist because of these and other unmeasured
fac-tors The potential confounding impacts of local
step-therapy guidelines, and personal insurance drug tiers
could also not be examined with available data The
timeframe for the data in this analysis started one year
after duloxetine was on the market in order to eliminate
‘early adopters’ of a new medication and better capture
a representative pattern in usual care settings However,
it is unclear if some of the differences observed here
were due to the fact that duloxetine was still the newer
antidepressant at this time and whether the observed
factors would persist if later data was utilized Greater
clinical severity and low initial dosing have been found
to be factors predicting earlier antidepressant switching
[24] and such patients may have preferentially tried the
newer medication We did not assess initial dose in this
work and additional confirmatory work utilizing more
recent data is warranted Finally, the descriptive cost changes over time may reflect regression to the mean that could be common to any added treatment rather than cost-offsets unique to SNRIs In the light of these potential limitations, the results of this study need to be further replicated and extended using different types of studies in broader patient and medication populations and with direct clinical data to aid in examining the impacts of depression severity and outcomes [19,25]
Clinical Implications
Initial SNRI care for patients with more complex MDD resembles a targeted approach in which clinicians draw subtle distinctions between duloxetine and venlafaxine
XR Duloxetine appears to be prescribed for somewhat more complicated and costly patients than venlafaxine
XR These treatment patterns suggest that both medica-tions have a place on formularies to allow for optimal patient matching, especially for patients not responding
to initial step therapy choices Effectiveness studies such
as STAR-D [2] and Randomized Trial Investigating SSRI Treatment (ARTIST) [26] demonstrate that most patients’ MDD does not remit with initial SSRI treat-ment, and that the need for second-stage or higher steps of care represent the norm rather than the excep-tion While clinical guidelines [11] tend to focus on first-line recommendations, less is known about optimal choices and targeting of patients needing treatment changes after initial nonremission There is also little
Figure 2 Pre- and post- 6-month average cost for treatment with duloxetine versus venlafaxine XR (Wilcoxon signed-rank test for pre and post comparison) Total cost, medical cost and pharmacy cost are significantly changed from prior 6-month to post 6-month (P < 0.05).
XR = extended release; Total = total cost; Medical = total medical cost; Rx = total pharmacy costs All comparisons of cost between cohorts (Wilcoxon rank-sum test) are statistically significant (P < 0.005).
Trang 9evidence-based guidance supporting optimal initial
matching to minimize nonremission and the risk that
patients will either discontinue treatment or refuse an
alternative regimen when first-line care fails
Conclusions
Patients with MDD receiving initial treatment with
duloxetine were more likely to be older and to have
comorbid medical conditions and complex prior
medi-cation treatment histories compared with their
counter-parts initially receiving venlafaxine XR Duloxetine
initiators were also more likely to have been under prior
psychiatric care, to have ≥8 unique medical conditions,
and to have used ≥3 unique pain medications within the
year before initiating SNRI treatment Further research
in more heterogeneous patient populations may
deline-ate more definitively the potential patient-reldeline-ated
out-comes and treatment cost consequences associated with
more optimally targeted SNRI treatments
Appendix
List of 17 medical categories; Table 4 (used for patients’
unique medical conditions)
Acknowledgements
The authors wish to thank Dr Doug Faries of Lilly USA, LLC, and Dr Xianchen
Liu of Eli Lilly and Company for their insightful comments on this manuscript,
as well as Johanna Grossman, PhD, and Stephen W Gutkin, of Rete Biomedical
Communications Corp (Wyckoff, NJ USA), for assistance in preparing the
manuscript This study was funded by Eli Lilly and Company (Indianapolis,
Indiana) A poster of this study was presented at the International Society for
Pharmacoeconomics and Outcomes Research, Toronto, May 6, 2008.
Author details
1 Lilly USA, LLC, Indianapolis, Indiana, USA 2 Global Health Outcomes, Eli Lilly
Authors ’ contributions Concept and design WY, YZ, RR, RWS; acquisition of data WY, YZ, RR; analysis and interpretation of data WY, YZ, RR, RWS; drafting of the manuscript WY, RWS; critical revision of the manuscript for important intellectual content
WY, YZ, RR, RWS; statistical analysis WY; obtaining funding WY; and supervision RWS All authors have read and approved the final manuscript Competing interests
This study and its report were supported and fully funded by Eli Lilly and Company (Indianapolis, Indiana), which had a role in study design; data acquisition and analysis; preparation and revision of the manuscript; and the decision to publish the findings Wenyu Ye, Yang Zhao, Rebecca L Robinson, Ralph W Swindle are full-time employees and minor shareholders
of Eli Lilly and Company, Indianapolis, IN.
Received: 8 January 2010 Accepted: 31 January 2011 Published: 31 January 2011
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Table 4 Medical Condition ICD-9-CM Code
Infectious and parasitic diseases 001-139
Nervous system and sense organs 320-389
Musculoskeletal system 710-739
ICD-9-CM = International Classification of Diseases, 9th Edition.
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Pre-publication history
The pre-publication history for this paper can be accessed here:
http://www.biomedcentral.com/1471-244X/11/19/prepub
doi:10.1186/1471-244X-11-19
Cite this article as: Ye et al.: Treatment patterns associated with
Duloxetine and Venlafaxine use for Major Depressive Disorder BMC
Psychiatry 2011 11:19.
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